The author of this new book on Gluten is Professor David Sanders who has an impressive resume in the coeliac world. He is a Professor of Gastroenterology and is the chair of the Coeliac UK Health Advisory Council among other notable appointments.
Who is this book for? It is for anyone who thinks gluten may be affecting them and provides guidance as to the medical reasons why this might be, including the fact the culprit may not always be gluten. It would also be useful for medical professionals, such as GPs and nutritionists who want a summary of the (fully referenced) research available on gluten and the link to various medical conditions, without all the hype often associated with books on gluten.
As a high level overview, you will find it interesting if you want to know more on:
- the history of gluten
- how coeliac disease, non coeliac gluten sensitivity and food allergies are diagnosed
- understanding the parts per million measure of gluten
- information on FODMAPS (fructose and other sugars that some people have difficulty digesting)
- IBS (Irritable Bowel Syndrome) & IBD (Inflammatory Bowel Disease)
- and how gluten may affect neurological problems, chronic fatigue/fibromylagia, fertility problems and more.
It became clear in reading ‘Gluten Attack’ that Prof Sanders is no ordinary doctor, because as well as being a thorough scientific researcher, he is also open minded. This comes through in the acceptance that patients do have a story to tell, and their symptom reports should not be dismissed just because the medical tests say that they don’t have X, Y or Z and that medicine is really a combination of science and art. As a qualified nutritionist, this really resonated with me.
What is gluten and how does it affect coeliacs?
Gluten is the term used to describe specific storage proteins in wheat (gliadin), rye (hordein), barley (secalin), and derivatives of these grains. The protein in oats (avenin) is more controversial (more in the book and also on the Coeliac UK website). Humans cannot completely digest gluten and it is this polypetide that the immune system sees as foreign and is the trigger for the autoimmune response in coeliac disease.
Removing gluten for coeliacs is critical due to the long term complications, not just the immediate unpleasant symptoms. One risk I was not fully aware of is that coeliacs have 10 times the risk for IBD than the general population. However, this usually would be microscopic colitis rather than the more serious conditions of Chron’s or Ulcerative Colitis.
Gluten is ubiquitous in the food supply (and not just in the obvious places!) and it is considered that the average person eats 15-20mg per day. The current European definition of gluten free is under 20 parts per million (ppm) and there is a good explanation of the meaning of this figure in the book. In Australia the definition of gluten free is ‘no detectable gluten’, which is a much stricter standard.
Whilst reading ‘Gluten Attack’, I was also reading a Cochrane Australia review, ‘Systematic Review of Safe Level of Gluten for People with Coeliac Disease’, which you can find on the Coeliac Australia website. This concludes that there is not currently a definitive safe level for all people with coeliac disease to consume, so further work needs to be done. I was particularly interested to read that the study that the current 20 ppm gluten free definition is derived from only had 39 patients – a small number by anyone’s standards!
Non coeliac gluten sensitivity
Some of Prof. Sanders research has been attempting to find why patients so often report reactions to gluten without the presence of coeliac disease. He notes that reports of non coeliac gluten sensitivity (NCGS) go back to the 1970’s, but it certainly seems to have gained traction over the last few years.
The latest research is indicating that there is subset of patients who have coeliac genes and higher than normal antibodies, but on biopsy there is not flattened villi, but increased intraepithelial lymphocytes. This indicates an immune response to gluten without the presence of coeliac disease in a subset of IBS patients.
Other conditions that have also been shown to improve on a gluten free diet (where antibodies have been raised), are neurological conditions such as ataxia (coordination problems), mental illness (eg schizophrenia), skin conditions (eg psoriasis), muscle conditions (eg fibromyalgia) and even low birth weights of children born to affected mothers. Some of the studies have been small or are in the early stages of investigation (see the relevant chapters in the book), but it does seem that there may be some people who are affected by gluten who do not have coeliac disease. There have even been some studies on dogs with movement disorders that have found they have raised intraepithelial lymphocytes and damaged villi.
Prof. Sanders has concluded that patients with the combination of coeliac genes and raised antibodies may be ‘coeliac lite’ patients (ie have an immune reaction, but not an autoimmune reaction). These patients could also benefit from a gluten free diet, however a lot more research still needs to be done!
As with coeliac disease, you should not put yourself on a gluten free diet before seeking medical advice (see Rule No.1 of 10 in the book!).
There is also discussion on how people may be confusing gluten with non gluten related symptoms. There is quite a lengthy discussion on FODMAPS (Fermentable Oligisaccharides, Disaccharides, Monoccharides and Polyols) and other non gluten components of wheat that may be triggering symptoms in those with IBS and IBD respectively.
As an Australian, I must give a shout out to the fantastic FODMAPS app produced by Monash University in Melbourne which is of great assistance to anyone following a low FODMAP diet (but please note you should see a dietitian before beginning this diet).
But why the rise in gluten related conditions?
Prof. Sanders has attempted to discuss reasons why we are seeing an increase in gluten related conditions. There are many theories, which range from wheat being relatively biologically new to humans, to the amount of wheat being eaten and of course the ‘hygiene hypothesis’. The early chapters have a good discussion on these theories (and more).
Prof. Sanders concludes that is it possible that gluten could become a public health problem. Its commercial use is unregulated and it “appears to have many unexplained effects and associations” (p146). Of course, only time will tell.
If you think you may have coeliac disease, you can start with the ‘is it coeliac disease?’ questionnaire on the Coeliac UK website and take the results to your GP.
I think ‘Gluten Attack’ is a really interesting read and provides a balanced view of the current research available on gluten. There are also some gluten free recipes at the end to get you thinking about gluten free alternatives.
You can buy Gluten Attack on Amazon UK (click link) for £12. For more information on Prof. Sanders see his website: www.profdavidsanders.co.uk
Declaration: I was sent a complimentary copy of the book to review.